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Verma A, Balian J, Hadaya J, Premji A, Shimizu T, Donahue T, Benharash P. Machine Learning-based Prediction of Postoperative Pancreatic Fistula Following Pancreaticoduodenectomy. Ann Surg 2024; 280:325-331. [PMID: 37947154 DOI: 10.1097/sla.0000000000006123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
OBJECTIVE The aim of this study was to develop a novel machine learning model to predict clinically relevant postoperative pancreatic fistula (CR-POPF) following pancreaticoduodenectomy (PD). BACKGROUND Accurate prognostication of CR-POPF may allow for risk stratification and adaptive treatment strategies for potential PD candidates. However, antecedent models, such as the modified Fistula Risk Score (mFRS), are limited by poor discrimination and calibration. METHODS All records entailing PD within the 2014 to 2018 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) were identified. In addition, patients undergoing PD at our institution between 2013 and 2021 were queried from our local data repository. An eXtreme Gradient Boosting (XGBoost) model was developed to estimate the risk of CR-POPF using data from the ACS NSQIP and evaluated using institutional data. Model discrimination was estimated using the area under the receiver operating characteristic (AUROC) and area under the precision recall curve (AUPRC). RESULTS Overall, 12,281 and 445 patients undergoing PD were identified within the 2014 to 2018 ACS NSQIP and our institutional registry, respectively. Application of the XGBoost and mFRS scores to the internal validation dataset revealed that the former model had significantly greater AUROC (0.72 vs 0.68, P <0.001) and AUPRC (0.22 vs 0.18, P <0.001). Within the external validation dataset, the XGBoost model remained superior to the mFRS with an AUROC of 0.79 (95% CI: 0.74-0.84) versus 0.75 (95% CI: 0.70-0.80, P <0.001). In addition, AUPRC was higher for the XGBoost model, compared with the mFRS. CONCLUSION Our novel machine learning model consistently outperformed the previously validated mFRS within internal and external validation cohorts, thereby demonstrating its generalizability and utility for enhancing prediction of CR-POPF.
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Affiliation(s)
- Arjun Verma
- Cardiovascular Outcomes Research Laboratories, Department of Surgery, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, CA
| | - Jeffrey Balian
- Cardiovascular Outcomes Research Laboratories, Department of Surgery, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, CA
| | - Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories, Department of Surgery, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, CA
- Department of Surgery, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, CA
| | - Alykhan Premji
- Department of Surgery, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, CA
- Department of Surgery, Division of Surgical Oncology, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, CA
| | - Takayuki Shimizu
- Department of Surgery, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, CA
- Department of Surgery, Division of Surgical Oncology, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, CA
| | - Timothy Donahue
- Department of Surgery, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, CA
- Department of Surgery, Division of Surgical Oncology, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, CA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, Department of Surgery, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, CA
- Department of Surgery, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, CA
- Department of Surgery, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, CA
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2
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Herzberg J, Strate T, Acs M, Piso P, Guraya SY, Honarpisheh H. Reduction of Postoperative Complications in Pancreatic Surgery by Standardizing Perioperative Management: An Observational Cohort Study. Visc Med 2024; 40:184-193. [PMID: 39157727 PMCID: PMC11326765 DOI: 10.1159/000539688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 06/04/2024] [Indexed: 08/20/2024] Open
Abstract
Introduction Resection for pancreatic malignancy remains the gold standard for cure. Postoperative morbidity continues to be high even after technical innovations. This study evaluates the effectiveness of a standard perioperative pancreatic oncological surgery step-by-step protocol in reducing organ-specific complications. Methods In this observational cohort study, we analyzed the outcomes of oncologic pancreatic head resections from 2015 to 2022 after the implementation of a standard perioperative fail-safe protocol and compared these data with a historical cohort (2013-2014). In the study group, all patients were treated with preoperative limited mechanical bowel preparation, administration of a somatostatin analog, and a "pancreatic duct tube" in pancreatoduodenectomy. The primary outcome measure was the occurrence of postoperative organ-specific complications. Results A total of 151 patients were included in this study. The rate of postoperative pancreatic fistula (grade B and C) in the fail-safe group was 4.2%. Other organ-specific complications as postoperative hemorrhage (2.5%) and delayed gastric emptying (9.2%) also occurred less frequent than before implementation of the fail-safe protocol. Conclusion The use of this standardized fail-safe protocol for oncologic pancreatoduodenectomy can lead to a low postoperative morbidity with improved surgical outcomes.
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Affiliation(s)
- Jonas Herzberg
- Department of Surgery, Krankenhaus Reinbek St. Adolf-Stift, Reinbek, Germany
| | - Tim Strate
- Department of Surgery, Krankenhaus Reinbek St. Adolf-Stift, Reinbek, Germany
| | - Miklos Acs
- Department of General and Visceral Surgery, Hospital Barmherzige Brüder, Regensburg, Germany
| | - Pompiliu Piso
- Department of General and Visceral Surgery, Hospital Barmherzige Brüder, Regensburg, Germany
| | - Salman Yousuf Guraya
- Clinical Sciences Department, College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
| | - Human Honarpisheh
- Department of Surgery, Krankenhaus Reinbek St. Adolf-Stift, Reinbek, Germany
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3
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Rykina-Tameeva N, Samra JS, Sahni S, Mittal A. Non-Surgical Interventions for the Prevention of Clinically Relevant Postoperative Pancreatic Fistula-A Narrative Review. Cancers (Basel) 2023; 15:5865. [PMID: 38136409 PMCID: PMC10741911 DOI: 10.3390/cancers15245865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 12/06/2023] [Accepted: 12/12/2023] [Indexed: 12/24/2023] Open
Abstract
Clinically relevant postoperative pancreatic fistula (CR-POPF) is the leading cause of morbidity and mortality after pancreatic surgery. Post-pancreatectomy acute pancreatitis (PPAP) has been increasingly understood as a precursor and exacerbator of CR-POPF. No longer believed to be the consequence of surgical technique, the solution to preventing CR-POPF may lie instead in non-surgical, mainly pharmacological interventions. Five databases were searched, identifying eight pharmacological preventative strategies, including neoadjuvant therapy, somatostatin and its analogues, antibiotics, analgesia, corticosteroids, protease inhibitors, miscellaneous interventions with few reports, and combination strategies. Two further non-surgical interventions studied were nutrition and fluids. New potential interventions were also identified from related surgical and experimental contexts. Given the varied efficacy reported for these interventions, numerous opportunities for clarifying this heterogeneity remain. By reducing CR-POPF, patients may avoid morbid sequelae, experience shorter hospital stays, and ensure timely delivery of adjuvant therapy, overall aiding survival where prognosis, particularly in pancreatic cancer patients, is poor.
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Affiliation(s)
- Nadya Rykina-Tameeva
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2050, Australia
- Kolling Institute of Medical Research, University of Sydney, St Leonards, NSW 2065, Australia
| | - Jaswinder S. Samra
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2050, Australia
- Upper GI Surgical Unit, Royal North Shore Hospital, St Leonards, NSW 2065, Australia
- Upper GI Surgical Unit, North Shore Private Hospital, St Leonards, NSW 2065, Australia
- Australian Pancreatic Centre, St Leonards, NSW 2065, Australia
| | - Sumit Sahni
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2050, Australia
- Kolling Institute of Medical Research, University of Sydney, St Leonards, NSW 2065, Australia
- Australian Pancreatic Centre, St Leonards, NSW 2065, Australia
| | - Anubhav Mittal
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2050, Australia
- Upper GI Surgical Unit, Royal North Shore Hospital, St Leonards, NSW 2065, Australia
- Upper GI Surgical Unit, North Shore Private Hospital, St Leonards, NSW 2065, Australia
- Australian Pancreatic Centre, St Leonards, NSW 2065, Australia
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4
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Meierhofer C, Fuegger R, Biebl M, Schoefl R. Pancreatic Fistulas: Current Evidence and Strategy-A Narrative Review. J Clin Med 2023; 12:5046. [PMID: 37568446 PMCID: PMC10419817 DOI: 10.3390/jcm12155046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 07/26/2023] [Accepted: 07/27/2023] [Indexed: 08/13/2023] Open
Abstract
Pancreatic fistulas are highly feared complications following surgery on or near the pancreas, abdominal trauma, or severe inflammation. These fistulas arise from leaks in the pancreatic ductal system, leading to various complications such as abscesses, delayed gastric emptying, and hemorrhage. Severe cases present with sepsis or organ failure, dramatically increasing mortality and morbidity. Risk factors include smoking, high BMI, male gender, age, and surgery-related factors like prolonged operation time and non-ligation of the main pancreatic duct. Therefore, treatment options and preventive measurements have become a hot topic in recent years. Studies have investigated the use of fibrin sealants, different closure methods, and less invasive surgical techniques. Treatment options consist of conservative measurements and the use of percutaneous drainage, prophylactic transpapillary stenting, and surgery in severe cases. As EUS has become widely available, transmural stenting started to influence the management of pancreatic fluid collections (PFCs). However, studies on its use for the management of pancreatic fistulas are lacking. Medical treatment options like somatostatin analogs and pasireotide have been investigated but yielded mixed results.
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Affiliation(s)
- Clara Meierhofer
- Department of Gastroenterology, Ordensklinikum Linz, 4010 Linz, Austria
| | | | - Matthias Biebl
- Department of Surgery, Ordensklinikum Linz, 4010 Linz, Austria
| | - Rainer Schoefl
- Department of Gastroenterology, Ordensklinikum Linz, 4010 Linz, Austria
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5
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Utria AF, Labadie KP, Abbasi A, Gui X, Pillarisetty VG, Park JO, Sham JG. A novel rat model for the study of postoperative pancreatic fistula. Lab Anim 2022; 56:519-527. [PMID: 35765854 DOI: 10.1177/00236772221107347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
While over the past several decades mortality after pancreatic surgery has decreased to <5%, postoperative morbidity remains remarkably high, ranging from 15% to 65%. The development of a postoperative pancreatic fistula (POPF) is a significant contributor to morbidity in patients undergoing pancreatic surgery. POPF can lead to life-threatening conditions such as intra-abdominal abscess, uncontrolled hemorrhage, sepsis, and death. Rates of POPF have not significantly changed over time, despite the introduction of multiple technical and pharmacologic interventions aimed at their treatment and prevention. Unfortunately, there are few POPF experimental models that have been described in the literature and existing models are unable to reliably reproduce the clinical sequelae of POPF, limiting the development of new methods to prevent and treat POPF. Herein, we describe a new rat experimental model that reliably creates a POPF via transection of the common pancreatic duct.
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Affiliation(s)
- Alan F Utria
- University of Iowa Hospitals and Clinics, Iowa City, USA
| | | | | | | | - Venu G Pillarisetty
- University of Washington, Seattle, USA.,Fred Hutchinson Cancer Center, Seattle, USA
| | - James O Park
- University of Washington, Seattle, USA.,Fred Hutchinson Cancer Center, Seattle, USA
| | - Jonathan G Sham
- University of Washington, Seattle, USA.,Fred Hutchinson Cancer Center, Seattle, USA
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6
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Yoon SJ, Lee O, Jung JH, Shin SH, Heo JS, Han IW. Prophylactic octreotide for postoperative pancreatic fistula in patients with pancreatoduodenectomy: Risk-stratified analysis. Medicine (Baltimore) 2022; 101:e29303. [PMID: 35665731 PMCID: PMC9276315 DOI: 10.1097/md.0000000000029303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 04/27/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Postoperative pancreatic fistula is one of the most critical complications following pancreatic surgery. This study aimed to evaluate the utility of selective prophylactic octreotide for patients at high risk of developing postoperative pancreatic fistula. METHODS From June 2019 to July 2020, 263 patients underwent pancreatoduodenectomy with pancreatojejunostomy at Samsung Medical Center. The individual fistula risk scores were calculated using a previously developed nomogram. The clinicopathological data of the patients were retrospectively reviewed. RESULTS There were 81 patients in the low-risk group and 182 patients in the high-risk group. No statistically significant differences were found in the rates of clinically relevant postoperative pancreatic fistula between octreotide group and the control group in all patients (15.0% vs 14.7%, P = .963) and in the high-risk group (16.1% vs 23.6%, P = .206). In risk factor analysis, postoperative octreotide was not an independent risk factor for clinically relevant pancreatic fistula in all patients and the high-risk group. Drain fluid amylase levels on the first postoperative day were significantly associated with clinically relevant postoperative pancreatic fistula, regardless of the individual risk. CONCLUSIONS The selective use of octreotide, even in high-risk patients, showed no protective effect against pancreatic fistula. Therefore, the routine use of postoperative octreotide is not recommended.
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7
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Kolbinger FR, Lambrecht J, Leger S, Ittermann T, Speidel S, Weitz J, Hoffmann RT, Distler M, Kühn JP. The image-based preoperative fistula risk score (preFRS) predicts postoperative pancreatic fistula in patients undergoing pancreatic head resection. Sci Rep 2022; 12:4064. [PMID: 35260701 PMCID: PMC8904506 DOI: 10.1038/s41598-022-07970-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 02/22/2022] [Indexed: 12/23/2022] Open
Abstract
Clinically relevant postoperative pancreatic fistula (CR-POPF) is a common severe surgical complication after pancreatic surgery. Current risk stratification systems mostly rely on intraoperatively assessed factors like manually determined gland texture or blood loss. We developed a preoperatively available image-based risk score predicting CR-POPF as a complication of pancreatic head resection. Frequency of CR-POPF and occurrence of salvage completion pancreatectomy during the hospital stay were associated with an intraoperative surgical (sFRS) and image-based preoperative CT-based (rFRS) fistula risk score, both considering pancreatic gland texture, pancreatic duct diameter and pathology, in 195 patients undergoing pancreatic head resection. Based on its association with fistula-related outcome, radiologically estimated pancreatic remnant volume was included in a preoperative (preFRS) score for POPF risk stratification. Intraoperatively assessed pancreatic duct diameter (p < 0.001), gland texture (p < 0.001) and high-risk pathology (p < 0.001) as well as radiographically determined pancreatic duct diameter (p < 0.001), gland texture (p < 0.001), high-risk pathology (p = 0.001), and estimated pancreatic remnant volume (p < 0.001) correlated with the risk of CR-POPF development. PreFRS predicted the risk of CR-POPF development (AUC = 0.83) and correlated with the risk of rescue completion pancreatectomy. In summary, preFRS facilitates preoperative POPF risk stratification in patients undergoing pancreatic head resection, enabling individualized therapeutic approaches and optimized perioperative management.
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Affiliation(s)
- Fiona R Kolbinger
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, TU Dresden, Fetscherstrasse 74, 01307, Dresden, Germany.
- Division of Translational Surgical Oncology, National Center for Tumor Diseases (NCT), Partner Site Dresden, Dresden, Germany.
- Else Kröner Fresenius Center for Digital Health (EKFZ), Technische Universität Dresden, Dresden, Germany.
| | - Julia Lambrecht
- Institute and Policlinic for Diagnostic and Interventional Radiology, University Hospital Carl Gustav Carus Dresden, TU Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Stefan Leger
- Division of Translational Surgical Oncology, National Center for Tumor Diseases (NCT), Partner Site Dresden, Dresden, Germany
- Else Kröner Fresenius Center for Digital Health (EKFZ), Technische Universität Dresden, Dresden, Germany
| | - Till Ittermann
- Institute for Community Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Stefanie Speidel
- Division of Translational Surgical Oncology, National Center for Tumor Diseases (NCT), Partner Site Dresden, Dresden, Germany
- Else Kröner Fresenius Center for Digital Health (EKFZ), Technische Universität Dresden, Dresden, Germany
| | - Jürgen Weitz
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, TU Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
- Else Kröner Fresenius Center for Digital Health (EKFZ), Technische Universität Dresden, Dresden, Germany
| | - Ralf-Thorsten Hoffmann
- Institute and Policlinic for Diagnostic and Interventional Radiology, University Hospital Carl Gustav Carus Dresden, TU Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Marius Distler
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, TU Dresden, Fetscherstrasse 74, 01307, Dresden, Germany.
- Else Kröner Fresenius Center for Digital Health (EKFZ), Technische Universität Dresden, Dresden, Germany.
| | - Jens-Peter Kühn
- Institute and Policlinic for Diagnostic and Interventional Radiology, University Hospital Carl Gustav Carus Dresden, TU Dresden, Fetscherstrasse 74, 01307, Dresden, Germany.
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8
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Tewari M, Swain JR, Mahendran R. Update on Management Periampullary/Pancreatic Head Cancer. Indian J Surg 2021. [DOI: 10.1007/s12262-019-02053-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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9
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Liu X, Pausch T, Probst P, Cui J, Wei J, Hackert T, Miao Y. Efficacy of Pasireotide for Prevention of Postoperative Pancreatic Fistula in Pancreatic Surgery: a Systematic Review and Meta-analysis. J Gastrointest Surg 2020; 24:1421-1429. [PMID: 32207077 DOI: 10.1007/s11605-019-04479-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 11/12/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Pasireotide was recently suggested for the prevention of postoperative pancreatic fistula (POPF) after pancreatic surgery. However, its efficacy remains to be controversially dicussed. Therefore, we conducted a systematic review and meta-analysis to assess the efficacy of pasireotide for preventing POPF after pancreatic surgery. METHOD A systematic literature search was conducted in PubMed, Web of Science, and The Cochrane Library to identify clinical studies investigating the efficacy of pasireotide after pancreatic surgery. The identified studies were critically appraised, and meta-analyses were then performed. The study was performed in accordance with PRISMA guidelines and was registered at the PROSPERO study database (CRD42018112334). RESULTS Four studies with a total of 919 patients were included: 418 with pasireotide treatment and 501 controls. Meta-analysis showed that pasireotide could reduce neither clinically relevant POPF rate (OR = 0.78; 95% CI, 0.49-1.24; P = 0.29) nor overall POPF rate (OR = 0.94; 95% CI, 0.60-1.48; P = 0.80) after pancreatic resections. There were no significant differences in delayed gastric emptying, mortality, and postoperative hospital stay after pancreatic surgery. However, pasireotide reduces readmission after pancreatic surgery (OR = 0.61; 95% CI, 0.44-0.85; P = 0.004). Subgroup analyses revealed that prophylactic use of pasireotide did not reduce the incidence of clinically relevant POPF after pancreaticoduodenectomy or distal pancreatectomy compared with the control. CONCLUSION Based on the available evidence, use of pasireotide may not reduce clinically relevant POPF as well as it may not improve postoperative course substantially after pancreatic surgery. Further investigator-initiated high-quality trials are needed.
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Affiliation(s)
- Xinchun Liu
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany.,Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.,Department of Gastrointestinal Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Thomas Pausch
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Pascal Probst
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Jiaqu Cui
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Jishu Wei
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Thilo Hackert
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Yi Miao
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.
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10
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Nakanishi K, Kanda M, Sakamoto J, Kodera Y. Is the measurement of drain amylase content useful for predicting pancreas-related complications after gastrectomy with systematic lymphadenectomy? World J Gastroenterol 2020; 26:1594-1600. [PMID: 32327908 PMCID: PMC7167417 DOI: 10.3748/wjg.v26.i14.1594] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 01/13/2020] [Accepted: 03/22/2020] [Indexed: 02/06/2023] Open
Abstract
Many studies investigating postoperative pancreatic fistula (POPF) after gastrectomy, including studies measuring drain amylase content (D-AMY) as a predictive factor have been reported. This article reviews previous studies and looks to the future of measuring D-AMY in patients after gastrectomy. The causes of pancreatic fluid leakage are; the parenchymal and/or thermal injury to the pancreas, and blunt injury to the pancreas by compression and retraction. Measurement of D-AMY to predict POPF has become common in clinical practice after pancreatic surgery and was later extended to the gastric surgery. Several studies have reported associations between D-AMY and POPF after gastrectomy, and the high value of D-AMY on postoperative day (POD) 1 was an independent risk factor. To improve both sensitivity and specificity, attempts have been made to enhance the predictive accuracy of factors on POD 1 as well as on POD 3 as combined markers. Although several studies have shown a high predictive ability of POPF, it has not necessarily been exploited in clinical practice. Many problems remain unresolved; ideal timing for measurement, optimal cut-off value, and means of intervention after prediction. Prospective clinical trial could be imperative in order to develop D-AMY measurement in common clinical practice for gastric surgery.
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Affiliation(s)
- Koki Nakanishi
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Mitsuro Kanda
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | | | - Yasuhiro Kodera
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
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11
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Li T, D'Cruz RT, Lim SY, Shelat VG. Somatostatin analogues and the risk of post-operative pancreatic fistulas after pancreatic resection - A systematic review & meta-analysis. Pancreatology 2020; 20:158-168. [PMID: 31980352 DOI: 10.1016/j.pan.2019.12.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 12/17/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Post-operative pancreatic fistula (POPF) is a common complication of pancreatic resection. Somatostatin analogues (SA) have been used as prophylaxis to reduce its incidence. The aim of this study is to appraise the current literature on the effects of SA prophylaxis on the prevention of POPF following pancreatic resection. METHODS The review of the literature was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data from studies that reported the effects of SA prophylaxis on POPF following pancreatic resection were extracted, to determine the effect of SA on POPF morbidity and mortality. RESULTS A total of 15 studies, involving 2221 patients, were included. Meta-analysis revealed significant reductions in overall POPF (Odds ratio: 0.65 (95% CI 0.53-0.81, p < 0.01)), clinically significant POPF (Odds ratio: 0.53 (95% CI 0.34-0.83, p < 0.01)) and overall morbidity (OR: 0.69 (95% CI: 0.50-0.95, p = 0.02)) following SA prophylaxis. There is no evidence that SA prophylaxis reduces mortality (OR: 1.10 (95%CI: 0.68-1.79, p = 0.68)). CONCLUSION SA prophylaxis following pancreatic resection reduces the incidence of POPF. However, mortality is unaffected.
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Affiliation(s)
- Tianpei Li
- Yong Loo Lin School of Medicine, National University, Singapore.
| | - Reuban Toby D'Cruz
- Department of General Surgery, National University Health System, Singapore
| | - Sheng Yang Lim
- Yong Loo Lin School of Medicine, National University, Singapore
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore
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12
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Influence of margin histology on development of pancreatic fistula following pancreatoduodenectomy. J Surg Res 2020; 246:315-324. [DOI: 10.1016/j.jss.2018.02.052] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 12/18/2017] [Accepted: 02/27/2018] [Indexed: 12/25/2022]
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13
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Howe JR, Merchant NB, Conrad C, Keutgen XM, Hallet J, Drebin JA, Minter RM, Lairmore TC, Tseng JF, Zeh HJ, Libutti SK, Singh G, Lee JE, Hope TA, Kim MK, Menda Y, Halfdanarson TR, Chan JA, Pommier RF. The North American Neuroendocrine Tumor Society Consensus Paper on the Surgical Management of Pancreatic Neuroendocrine Tumors. Pancreas 2020; 49:1-33. [PMID: 31856076 PMCID: PMC7029300 DOI: 10.1097/mpa.0000000000001454] [Citation(s) in RCA: 198] [Impact Index Per Article: 49.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This manuscript is the result of the North American Neuroendocrine Tumor Society consensus conference on the surgical management of pancreatic neuroendocrine tumors from July 19 to 20, 2018. The group reviewed a series of questions of specific interest to surgeons taking care of patients with pancreatic neuroendocrine tumors, and for each, the available literature was reviewed. What follows are these reviews for each question followed by recommendations of the panel.
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Affiliation(s)
- James R. Howe
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA
| | | | - Claudius Conrad
- Department of Surgery, St. Elizabeth Medical Center, Tufts University School of Medicine, Boston, MA
| | | | - Julie Hallet
- Department of Surgery, University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Jeffrey A. Drebin
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Rebecca M. Minter
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | | | - Herbert J. Zeh
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Steven K. Libutti
- §§ Department of Surgery, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Gagandeep Singh
- Department of Surgery, City of Hope Comprehensive Cancer Center, Duarte, CA
| | - Jeffrey E. Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Thomas A. Hope
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA
| | - Michelle K. Kim
- Department of Medicine, Mt. Sinai Medical Center, New York, NY
| | - Yusuf Menda
- Department of Radiology, University of Iowa Carver College of Medicine, Iowa City, IA
| | | | - Jennifer A. Chan
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Rodney F. Pommier
- Department of Surgery, Oregon Health & Sciences University, Portland, OR
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14
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Di Donato V, Bardhi E, Tramontano L, Capomacchia FM, Palaia I, Perniola G, Plotti F, Angioli R, Giancotti A, Muzii L, Panici PB. Management of morbidity associated with pancreatic resection during cytoreductive surgery for epithelial ovarian cancer: A systematic review. Eur J Surg Oncol 2019; 46:694-702. [PMID: 31806515 DOI: 10.1016/j.ejso.2019.11.516] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 11/09/2019] [Accepted: 11/18/2019] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION In ovarian cancer (OC), survival benefit in case of complete cytoreduction with absence of residual tumor has been clearly demonstrated; however, it often requires extensive surgery. Particularly, pancreatic resection during cytoreduction, may severely impact perioperative morbidity and mortality. OBJECTIVES The aim of this systematic review is to evaluate complication rates and related optimal management of ovarian cancer patients undergoing pancreatic resection as part of cytoreductive surgery. METHODS Literature was searched for relevant records reporting distal pancreatectomy for advanced ovarian cancer. All cohorts were rated for quality. We focused our analysis on complications related to pancreatic surgical procedures evaluating the following outcomes: pancreatic fistula (PF), abdominal abscess, pancreatitis, iatrogenic diabetes, hemorrhage from splenic vessels and pancreatic-surgery-related mortality. RESULTS The most frequent complication reported was PF. Similar rates of PF were reported after hand-sewn (20%) or stapled closure (24%). Continued drainage is the standard treatment, and often, the leak can be managed conservatively and does not require re-intervention. Abdominal abscess is the second most frequent complication and generally follows a non-adequately drained PF and often required re-laparotomy. Pancreatitis is a rare event that could be treated conservatively; however, death can occur in case of necrotic evolution. Cases of post-operative hemorrhage due to splenic vessel bleeding have been described and represent an emergency. CONCLUSIONS Knowledge of pancreatic surgery and management of possible complications ought to be present in the oncologic-gynecologic armamentarium. All patients should be referred to specialized, dedicated, tertiary centers in order to reduce, promptly recognize and optimally manage complications.
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Affiliation(s)
- Violante Di Donato
- Department of Maternal and Child Health and Urological Sciences, "Sapienza" University of Rome, Policlinico Umberto I, Viale Del Policlinico 155, 00161, Rome, Italy
| | - Erlisa Bardhi
- Department of Maternal and Child Health and Urological Sciences, "Sapienza" University of Rome, Policlinico Umberto I, Viale Del Policlinico 155, 00161, Rome, Italy.
| | - Luca Tramontano
- Department of Maternal and Child Health and Urological Sciences, "Sapienza" University of Rome, Policlinico Umberto I, Viale Del Policlinico 155, 00161, Rome, Italy
| | - Filippo Maria Capomacchia
- Department of Maternal and Child Health and Urological Sciences, "Sapienza" University of Rome, Policlinico Umberto I, Viale Del Policlinico 155, 00161, Rome, Italy
| | - Innocenza Palaia
- Department of Maternal and Child Health and Urological Sciences, "Sapienza" University of Rome, Policlinico Umberto I, Viale Del Policlinico 155, 00161, Rome, Italy
| | - Giorgia Perniola
- Department of Maternal and Child Health and Urological Sciences, "Sapienza" University of Rome, Policlinico Umberto I, Viale Del Policlinico 155, 00161, Rome, Italy
| | - Francesco Plotti
- Department of Gynecology, University of Rome "Campus Bio-Medico", Via Álvaro Del Portillo, 21, 00128, Rome, Italy
| | - Roberto Angioli
- Department of Gynecology, University of Rome "Campus Bio-Medico", Via Álvaro Del Portillo, 21, 00128, Rome, Italy
| | - Antonella Giancotti
- Department of Maternal and Child Health and Urological Sciences, "Sapienza" University of Rome, Policlinico Umberto I, Viale Del Policlinico 155, 00161, Rome, Italy
| | - Ludovico Muzii
- Department of Maternal and Child Health and Urological Sciences, "Sapienza" University of Rome, Policlinico Umberto I, Viale Del Policlinico 155, 00161, Rome, Italy
| | - Pierluigi Benedetti Panici
- Department of Maternal and Child Health and Urological Sciences, "Sapienza" University of Rome, Policlinico Umberto I, Viale Del Policlinico 155, 00161, Rome, Italy
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15
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Adiamah A, Arif Z, Berti F, Singh S, Laskar N, Gomez D. The Use of Prophylactic Somatostatin Therapy Following Pancreaticoduodenectomy: A Meta-analysis of Randomised Controlled Trials. World J Surg 2019; 43:1788-1801. [PMID: 30798417 DOI: 10.1007/s00268-019-04956-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Prophylactic administration of somatostatin analogues (SA) to reduce the incidence of post-operative pancreatic fistula (POPF) remains contentious. This meta-analysis evaluated its impact on outcomes following pancreaticoduodenectomy (PD). METHODS The EMBASE, MEDLINE and Cochrane databases were searched for randomised controlled trials (RCTs) investigating prophylactic SA following PD. Comparative effects were summarised as odds ratio and weighted mean difference based on an intention to treat. Quantitative pooling of the effect sizes was derived using the random-effects model. MAIN RESULTS Twelve RCTs were included involving 1615 patients [SA-treated group (n = 820) and control group (n = 795)]. The SA used included somatostatin-14, pasireotide, vapreotide and octreotide. Pooling of the data showed no significant benefit of its use for the primary outcome measure of all grades of POPF, odds ratio (OR) 0.73 [95% confidence interval (CI), 0.51-1.05, p = 0.09] and clinically relevant POPF, OR 0.48 [95% CI, 0.22-1.06, p = 0.07]. There were no benefits in the secondary outcome measures of delayed gastric emptying, OR 0.98 [95% CI, 0.57-1.69, p = 0.94]; infected abdominal collections, OR 0.80 [95% CI, 0.44-1.43, p = 0.80]; reoperation rates, OR 1.24 [95% CI, 0.73-2.13, p = 0.42]; duration of hospital stay, - 0.23 [95% CI - .59 to 1.13, p = 0.74]; and mortality, 1.78 [95% CI, 0.94-3.39, p = 0.08]. CONCLUSION SA did not improve the post-operative outcomes following PD, including reducing the incidence of POPF. The routine administration of SA cannot be recommended following PD.
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Affiliation(s)
- A Adiamah
- Department of Hepatobiliary and Pancreatic Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, E Floor, West Block, Derby Road, Nottingham, NG7 2UH, UK
| | - Z Arif
- Department of Hepatobiliary and Pancreatic Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, E Floor, West Block, Derby Road, Nottingham, NG7 2UH, UK
| | - F Berti
- Department of Hepatobiliary and Pancreatic Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, E Floor, West Block, Derby Road, Nottingham, NG7 2UH, UK
| | - S Singh
- Department of Hepatobiliary and Pancreatic Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, E Floor, West Block, Derby Road, Nottingham, NG7 2UH, UK
| | - N Laskar
- Department of Hepatobiliary and Pancreatic Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, E Floor, West Block, Derby Road, Nottingham, NG7 2UH, UK
| | - D Gomez
- Department of Hepatobiliary and Pancreatic Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, E Floor, West Block, Derby Road, Nottingham, NG7 2UH, UK.
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16
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Wakahara T, Kanemitsu K, Asari S, Tsuchida S, Ueno N, Toyokawa A, Sasako M. The Combined Use of Drainage Amylase Concentration and Serum C-reactive Protein as Predictors of Pancreas-Related Complications after Elective Gastrectomy. Oncology 2019; 98:111-116. [PMID: 31600759 DOI: 10.1159/000503581] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 09/17/2019] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Postoperative pancreas-related complications (PPRC) can cause critical conditions, including sepsis and intra-abdominal bleeding. Thus, it is important to identify patients who are at risk of clinically significant PPRC as early as possible in the postoperative period. Some authors have reported the use of amylase concentration of the drainage fluid (dAmy) to predict PPRC. However, the positive predictive value of dAmy alone is not sufficient. OBJECTIVE The aim of this study is to evaluate the predictive value of combined use of dAmy and serum C-reactive protein (sCRP) for PPRC. METHODS The clinicopathological data of 327 patients who underwent elective gastrectomy for gastric cancer were reviewed. There were 18 patients who developed PPRC. Univariate and multivariate analyses were conducted to identify the risk factors of PPRC. Receiver operating characteristic curves were used to identify the cut-off values of dAmy and sCRP on postoperative day 3 (dAmy3 and sCRP3) to predict the risk of PPRC. RESULTS In the multivariate analysis, splenectomy alone correlated with PPRC. The cut-off values of dAmy3 and sCRP3 were 761 IU/L and 15.15 mg/dL, respectively. Among the 17 patients with both dAmy3 and sCRP3 above the thresholds, 10 (58.8%) had PPRC with Clavien-Dindo classification (CD) ≥II and 7 (41.2%) had PPRC with CD ≥III. In contrast, among the 236 patients with both parameters below the thresholds, 233 (98.7%) did not develop PPRC, and only 1 (0.4%) had PPRC with CD ≥III. CONCLUSIONS Splenectomy correlates with PPRC, which is consistent with results from large clinical trials. A combined use of dAmy3 and sCRP3 can be useful in predicting the risks of PPRC.
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Affiliation(s)
| | | | - Sadaki Asari
- Department of Surgery, Yodogawa Christian Hospital, Osaka, Japan
| | - Shinobu Tsuchida
- Department of Surgery, Yodogawa Christian Hospital, Osaka, Japan
| | - Nozomi Ueno
- Department of Surgery, Yodogawa Christian Hospital, Osaka, Japan
| | - Akihiro Toyokawa
- Department of Surgery, Yodogawa Christian Hospital, Osaka, Japan
| | - Mitsuru Sasako
- Department of Surgery, Yodogawa Christian Hospital, Osaka, Japan
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17
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Yuan F, Essaji Y, Belley-Cote EP, Gafni A, Latchupatula L, Ruo L, Serrano PE. Postoperative complications in elderly patients following pancreaticoduodenectomy lead to increased postoperative mortality and costs. A retrospective cohort study. Int J Surg 2018; 60:204-209. [DOI: 10.1016/j.ijsu.2018.11.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 11/14/2018] [Indexed: 12/17/2022]
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18
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Barreto SG, Dirkzwager I, Windsor JA, Pandanaboyana S. Predicting post‐operative pancreatic fistulae using preoperative pancreatic imaging: a systematic review. ANZ J Surg 2018; 89:659-665. [DOI: 10.1111/ans.14891] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 08/19/2018] [Accepted: 09/02/2018] [Indexed: 02/06/2023]
Affiliation(s)
- Savio G. Barreto
- Hepatobiliary and Oesophagogastric Unit, Division of Surgery and Perioperative MedicineFlinders Medical Centre Adelaide South Australia Australia
- School of Medicine, Faculty of Medicine, Nursing and Health SciencesFlinders University Adelaide South Australia Australia
| | - Ilse Dirkzwager
- Department of RadiologyAuckland City Hospital Auckland New Zealand
| | - John A. Windsor
- Department of Surgery, Faculty of Medical and Health SciencesThe University of Auckland Auckland New Zealand
- HBP Unit, Department of General SurgeryAuckland City Hospital Auckland New Zealand
| | - Sanjay Pandanaboyana
- Department of Surgery, Faculty of Medical and Health SciencesThe University of Auckland Auckland New Zealand
- HBP Unit, Department of General SurgeryAuckland City Hospital Auckland New Zealand
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19
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Abstract
BACKGROUND Pancreatic anastomosis is the Achilles heel of pancreatic surgery. Despite substantial progress in surgical techniques the rate of postoperative pancreatic fistulas remains very high. For this reason various supportive measures to secure pancreatic anastomoses are of continuing interest. OBJECTIVE This review presents the newest evidence-based data on supportive measures designed to secure a pancreatic anastomosis. MATERIAL AND METHODS The most recent meta-analyses, randomized controlled trials and the largest retrospective studies on the role of pancreatic duct stenting, double loop reconstruction, autologous patches and drainage in pancreaticoduodenectomy were taken into account. The value of somatostatin analogues, perioperative nutrition and fluid management is critically discussed. RESULTS The existing body of evidence on supportive measures is insufficient and remains controversial. The use of somatostatin analogues, drainages and restrictive perioperative fluid management has proven effective. In contrast, routine stenting of the pancreatic duct cannot be recommended. Other approaches, such as double loop reconstruction and use of autologous patches lack sufficient evidence. CONCLUSION Meticulous surgical technique and surgeon experience remain the cornerstones of performing a safe pancreatic anastomosis; however, some additional supportive measures seem to have significant potential and should be further investigated in large and well-designed prospective clinical trials.
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Affiliation(s)
- O Belyaev
- Klinik für Allgemein- und Viszeralchirurgie, St. Josef-Hospital, Ruhr-Universiät Bochum, Gudrunstr. 56, 44791, Bochum, Deutschland.
| | - W Uhl
- Klinik für Allgemein- und Viszeralchirurgie, St. Josef-Hospital, Ruhr-Universiät Bochum, Gudrunstr. 56, 44791, Bochum, Deutschland
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20
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El Nakeeb A, ElGawalby A, A Ali M, Shehta A, Hamed H, El Refea M, Moneer A, Abd El Rafee A. Efficacy of octreotide in the prevention of complications after pancreaticoduodenectomy in patients with soft pancreas and non-dilated pancreatic duct: A prospective randomized trial. Hepatobiliary Pancreat Dis Int 2018; 17:59-63. [PMID: 29428106 DOI: 10.1016/j.hbpd.2018.01.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 11/02/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND The efficacy of octreotide to prevent postoperative pancreatic fistula (POPF) of pancreaticoduodenectomy (PD) is still controversial. This study aimed to evaluate the effect of postoperative use of octreotide on the outcomes after PD. METHODS This is a prospective randomized controlled trial for postoperative use of octreotide in patients undergoing PD. Patients with soft pancreas and pancreatic duct < 3 mm were randomized to 2 groups. Group I did not receive postoperative octreotide. Group II received postoperative octreotide. The primary end of the study is to compare the rate of POPF. RESULTS A total of 104 patients were included in the study and were divided into two randomized groups. There were no significant difference in overall complications and its severity. POPF occurred in 11 patients (21.2%) in group I and 10 (19.2%) in group II, without statistical significance (P = 0.807). Also, there was no significant differences between both groups regarding the incidence of biliary leakage (P = 0.083), delayed gastric emptying (P = 0.472), and early postoperative mortality (P = 0.727). CONCLUSIONS Octreotide did not reduce postoperative morbidities, reoperation and mortality rate. Also, it did not affect the incidence of POPF and its clinically relevant variants.
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Affiliation(s)
- Ayman El Nakeeb
- Gastroenterology Surgical Center, Mansoura University, Mansoura 35516, Egypt.
| | - Ahmed ElGawalby
- Gastroenterology Surgical Center, Mansoura University, Mansoura 35516, Egypt
| | - Mahmoud A Ali
- Gastroenterology Surgical Center, Mansoura University, Mansoura 35516, Egypt
| | - Ahmed Shehta
- Gastroenterology Surgical Center, Mansoura University, Mansoura 35516, Egypt
| | - Hosam Hamed
- Gastroenterology Surgical Center, Mansoura University, Mansoura 35516, Egypt
| | - Mohamed El Refea
- Gastroenterology Surgical Center, Mansoura University, Mansoura 35516, Egypt
| | - Ahmed Moneer
- Gastroenterology Surgical Center, Mansoura University, Mansoura 35516, Egypt
| | - Ahmed Abd El Rafee
- Gastroenterology Surgical Center, Mansoura University, Mansoura 35516, Egypt
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21
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Dilek ON, Özşay O, Acar T, Gür EÖ, Çelik SC, Cengiz F, Cin N, Hacıyanlı M. Postoperative hemorrhage complications following the Whipple procedure. Turk J Surg 2018; 35:136-141. [PMID: 32550319 DOI: 10.5578/turkjsurg.3758] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 04/20/2017] [Indexed: 12/28/2022]
Abstract
Objectives Although the Whipple operation is an essential surgical technique, its high morbidity (30% to 60%) and mortality (5%) are problems to be addressed. The incidence of postoperative hemorrhage has been reported between 5% and 16% in the literature. In this study, the data and results regarding postoperative hemorrhage complications from our clinic were evaluated. Material and Methods The files of 185 patients who had undergone Whipple operation in our hospital in the last five years were evaluated retrospectively, and the causes of hemorrhage were attempted to be determined. Results It was found that 6 out of the 13 (7%) patients who had hemorrhage died. In six of there 13 cases, hemorrhage occurred due to fistulas from the portal vein, gastroduodenal artery, and pancreatic arteries at variable periods. Two cases were found to have developed disseminated intravascular coagulation as a result of sepsis. Early intervention was performed in two cases who bled from the meso veins and in one case who bled from the portal vein. Laparotomy and hemostasis were performed in a patient who bled from the gastric anastomosis line. In a patient who had been taking low molecular weight heparin, bleeding from the drains and nasogastric tube stopped following the cessation of the drug. Conclusion Preventive procedures such as connection of the vascular structures, use of vascular sealants, omental patching during surgery, and reducing the risk of complications by using somatostatin analogs were performed to prevent hemorrhages after Whipple operations. In addition to standard methods, angiography and embolization have emerged as effective methods in the diagnosis and treatment of hemorrhages. Furthermore, determination and elimination of independent risk factors, such as jaundice, affecting fistula formation and bleeding in the perioperative period, is important for prevention.
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Affiliation(s)
- Osman Nuri Dilek
- İzmir Katip Çelebi Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, İzmir, Türkiye
| | - Oğuzhan Özşay
- Atatürk Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İzmir, Türkiye
| | - Turan Acar
- Atatürk Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İzmir, Türkiye
| | - Emine Özlem Gür
- İzmir Katip Çelebi Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, İzmir, Türkiye
| | - Salih Can Çelik
- Atatürk Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İzmir, Türkiye
| | - Fevzi Cengiz
- Atatürk Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İzmir, Türkiye
| | - Nejat Cin
- Atatürk Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İzmir, Türkiye
| | - Mehmet Hacıyanlı
- İzmir Katip Çelebi Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, İzmir, Türkiye
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22
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Han X, Xu Z, Cao S, Zhao Y, Wu W. The effect of somatostatin analogues on postoperative outcomes following pancreatic surgery: A meta-analysis. PLoS One 2017; 12:e0188928. [PMID: 29211787 PMCID: PMC5718483 DOI: 10.1371/journal.pone.0188928] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 11/15/2017] [Indexed: 12/27/2022] Open
Abstract
Background Leakage from the pancreatic stump is a leading cause of morbidity following pancreatic surgery. It is essential to evaluate the effect of somatostatin analogues (SAs) following pancreatic surgery by analyzing all recent clinical trials. Data sources We performed a literature search in the Medline, EMBASE, Cochrane Central Register of Controlled Trials and Web of Science databases up to May 29, 2016. Publication bias was assessed with Egger’s test. Study quality was assessed using the Jadad Composite Scale. Conclusions Twelve clinical trials involving 1703 patients from Jan 1st, 2000 to May 29th, 2016 were included in the study. With improvements in surgical management and peri-operative patient care, prophylactic use of somatostatin and its analogues reduced the overall incidence of pancreatic fistulas (RR 0.72, 95% CI 0.55–0.94; p = 0.02) and decreased the post-operative hospital stay after pancreatic surgery (the weighted mean difference was -1.06, 95% CI-1/88 to -0.23; p = 0.01). Other post-operative outcomes did not change significantly with the use of somatostatin analogues.
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Affiliation(s)
- Xianlin Han
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Zhiyan Xu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Shaobo Cao
- Department of Vascular Surgery, Wuhan Central Hospital, Tongji Medical College, Huazhong University of science and Technology, Wuhan, China
| | - Yupei Zhao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Wenming Wu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
- * E-mail:
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23
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Johnsen NV, Betzold RD, Guillamondegui OD, Dennis BM, Stassen NA, Bhullar I, Ibrahim JA. Surgical Management of Solid Organ Injuries. Surg Clin North Am 2017; 97:1077-1105. [PMID: 28958359 DOI: 10.1016/j.suc.2017.06.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Surgery used to be the treatment of choice in patients with solid organ injuries. This has changed over the past 2 decades secondary to advances in noninvasive diagnostic techniques, increased availability of less invasive procedures, and a better understanding of the natural history of solid organ injuries. Now, nonoperative management (NOM) has become the initial management strategy used for most solid organ injuries. Even though NOM has become the standard of care in patients with solid organ injuries in most trauma centers, surgeons should not hesitate to operate on a patient to control life-threatening hemorrhage.
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Affiliation(s)
- Niels V Johnsen
- Urological Surgery, Department of Urological Surgery, Vanderbilt University Medical Center, A-1302 Medical Center North, Nashville, TN 37232, USA
| | - Richard D Betzold
- Division of Trauma, Surgical Critical Care, Emergency General Surgery, Department of Surgery, Vanderbilt University Medical Center, 1211 21st Avenue South, 404 Medical Arts Building, Nashville, TN 37212, USA
| | - Oscar D Guillamondegui
- Division of Trauma, Surgical Critical Care, Emergency General Surgery, Department of Surgery, Vanderbilt University Medical Center, 1211 21st Avenue South, 404 Medical Arts Building, Nashville, TN 37212, USA
| | - Bradley M Dennis
- Division of Trauma, Surgical Critical Care, Emergency General Surgery, Department of Surgery, Vanderbilt University Medical Center, 1211 21st Avenue South, 404 Medical Arts Building, Nashville, TN 37212, USA.
| | - Nicole A Stassen
- Surgical Critical Care Fellowship and Surgical Sub-Internship, University of Rochester, Kessler Family Burn Trauma Intensive Care Unit, 601 Elmwood Avenue, Box Surg, Rochester, NY 14642, USA
| | - Indermeet Bhullar
- Orlando Health Physicians Surgical Group, Orlando Regional Medical Center, 86 West Underwood, Suite 201, Orlando, FL 32806, USA
| | - Joseph A Ibrahim
- Orlando Health Physicians Surgical Group, Orlando Regional Medical Center, 86 West Underwood, Suite 201, Orlando, FL 32806, USA
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24
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Management of adult pancreatic injuries: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2017; 82:185-199. [PMID: 27787438 DOI: 10.1097/ta.0000000000001300] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Traumatic injury to the pancreas is rare but is associated with significant morbidity and mortality, including fistula, sepsis, and death. There are currently no practice management guidelines for the medical and surgical management of traumatic pancreatic injuries. The overall objective of this article is to provide evidence-based recommendations for the physician who is presented with traumatic injury to the pancreas. METHODS The MEDLINE database using PubMed was searched to identify English language articles published from January 1965 to December 2014 regarding adult patients with pancreatic injuries. A systematic review of the literature was performed, and the Grading of Recommendations Assessment, Development and Evaluation framework was used to formulate evidence-based recommendations. RESULTS Three hundred nineteen articles were identified. Of these, 52 articles underwent full text review, and 37 were selected for guideline construction. CONCLUSION Patients with grade I/II injuries tend to have fewer complications; for these, we conditionally recommend nonoperative or nonresectional management. For grade III/IV injuries identified on computed tomography or at operation, we conditionally recommend pancreatic resection. We conditionally recommend against the routine use of octreotide for postoperative pancreatic fistula prophylaxis. No recommendations could be made regarding the following two topics: optimal surgical management of grade V injuries, and the need for routine splenectomy with distal pancreatectomy. LEVEL OF EVIDENCE Systematic review, level III.
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25
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Wang C, Zhao X, You S. Efficacy of the prophylactic use of octreotide for the prevention of complications after pancreatic resection: An updated systematic review and meta-analysis of randomized controlled trials. Medicine (Baltimore) 2017; 96:e7500. [PMID: 28723761 PMCID: PMC5521901 DOI: 10.1097/md.0000000000007500] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The use of octreotide prophylaxis in the prevention of complications after pancreatic resection remains controversial. The aim of this systematic review and meta-analysis was to evaluate the efficacy of octreotide prophylactic treatment to prevent complications after pancreatic resection. METHODS Five databases (PubMed, Medline, SinoMed, Embase, and Cochrane Library) were searched for eligible studies from 1980 to November 2016 with the limitation of human subjects and randomized controlled trials (RCTs). Data were extracted independently and were analyzed using RevMan statistical software version 5.3 (Cochrane Collaboration, http://tech.cochrane.org/revman/download). Weighted mean differences (WMDs), risk ratios (RRs), and 95% confidence intervals (CIs) were calculated. Cochrane Collaboration risk of bias tool was used to assess the risk of bias. RESULTS Twelve RCTs comprising 1902 patients were identified as eligible. The methodological quality of the trials ranged from low to moderate. A pooled analysis of effectiveness based on the data from each study revealed that octreotide could significantly reduce the rate of pancreatic fistula (PF) after pancreatic resection (RR = 0.75, 95% CI = 0.57-0.98, P = .04). The same findings were discovered in multicenter and European subgroups with a subgroup analysis; no obvious differences were noted in American, Asian, and single-center subgroup analyses. An equal effect was observed between the use or non-use of octreotide groups regarding mortality (RR = 1.24, 95% CI = 0.77-2.02, P = .38). Octreotide had no advantages in regards to mortality improvement. The total numbers of complications associated with the use or non-use of octreotide were similar (RR = 0.77, 95% CI = 0.58-1.03, P = .08). Among the high-risk group, octreotide was more effective in reducing complications (RR = 0.61, 95% CI = 0.46-0.82, P = .0009). Compared with the patients who did not receive prophylactic treatment, the patients who underwent pancreatic resection benefited from octreotide because it had better efficacy in preventing fluid collection and postoperative pancreatitis. CONCLUSION The prophylactic use of octreotide is suitable for preventing postoperative complications, especially PF and fluid collection as well as postoperative pancreatitis. However, no obvious differences were noted regarding mortality. In view of the clinical heterogeneity and varying definitions of PF, whether these conclusions are broadly applicable should be further determined in future studies.
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Affiliation(s)
- Chunli Wang
- Department of General Surgery, Tianjin Medical University General Hospital
| | - Xin Zhao
- Nankai Clinical School, Tianjin Medical University, Tianjin, China
| | - Shengyi You
- Department of General Surgery, Tianjin Medical University General Hospital
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The Cost of Postoperative Pancreatic Fistula Versus the Cost of Pasireotide: Results from a Prospective Randomized Trial. Ann Surg 2017; 265:11-16. [PMID: 27429029 DOI: 10.1097/sla.0000000000001892] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE The objective of this study was to determine the costs of clinically significant postoperative pancreatic fistula (POPF) and to evaluate the cost-effectiveness of routine pasireotide use. SUMMARY OF BACKGROUND DATA We recently completed a prospective randomized trial that demonstrated an 11.7% absolute risk reduction of clinically significant POPF with use of perioperative pasireotide in patients undergoing pancreaticoduodenectomy or distal pancreatectomy [POPF: pasireotide (n = 152), 9% vs placebo (n = 148), 21%; P = 0.006]. METHODS An institutional modeling system was utilized to obtain total direct cost estimates from the 300 patients included in the trial. This system identified direct costs of hospitalization, physician fees, laboratory tests, invasive procedures, outpatient encounters, and readmissions. Total direct costs were calculated from the index admission to 90 days after resection. Costs were converted to Medicare proportional dollars (MP$). RESULTS Clinically significant POPF occurred in 45 of the 300 randomized patients (15%). The mean total cost for all patients was MP$23,400 (MP$8,000 - MP$202,500). The mean cost for those who developed clinically significant POPF was MP$39,700 (MP$13,800 - MP$202,500) versus MP$20,500 (MP$8,000 - MP$62,900) for those who did not (P = 0.001). The mean cost of pasireotide within the treatment group (n = 152) was MP$3,300 (MP$300 - MP$3,800). The mean cost was lower in the pasireotide (n = 152) group than the placebo (n = 148) group; however, this did not reach statistical significance (pasireotide, MP$22,800 vs placebo, MP$23,900: P = 0.571). CONCLUSIONS The development of POPF nearly doubled the total cost of pancreatic resection. In this randomized trial, the routine use of pasireotide significantly reduced the occurrence of POPF without increasing the overall cost of care.
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Pasireotide for the Prevention of Pancreatic Fistula Following Pancreaticoduodenectomy: A Cost-effectiveness Analysis. Ann Surg 2017; 265:2-10. [PMID: 27537539 DOI: 10.1097/sla.0000000000001889] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To determine the cost-effectiveness of perioperative administration of pasireotide for reduction of pancreatic fistula (PF). SUMMARY PF is a major complication following pancreaticoduodenectomy (PD), associated with significant morbidity and healthcare-related costs. Pasireotide is a novel multireceptor ligand somatostatin analogue, which has been demonstrated to reduce the incidence of PF following pancreas resection; however, the drug cost is significant. This study sought to estimate the cost-effectiveness of routine administration of pasireotide to patients undergoing PD, compared with no intervention from the perspective of the hospital system. METHODS A decision-analytic model was developed to compare costs for perioperative administration of pasireotide versus no pasireotide. The model was populated using an institutional database containing all PDs performed 2002 to 2012 at a single institution, including data regarding clinically significant PF (International Study Group on Pancreatic Fistula Grade B or C) and hospital-related inpatient costs for 90 days following PD, converted to 2014 $USD. Relative risk of PF associated with pasireotide was estimated from the published literature. Deterministic and probabilistic sensitivity analyses were performed to test robustness of the model. RESULTS Mean institutional cost of index admissions was $67,417 and $31,950 for patients with and without PF, respectively. Pasireotide was the dominant strategy, associated with savings of $1685, and a mean reduction of 1.5 days length of stay. Univariate sensitivity analyses demonstrated cost-savings down to a PF rate of 5.6%, up to a relative risk of PF of 0.775, and up to a drug cost of $2817. Probabilistic sensitivity analysis showed 79% of simulations were cost saving. CONCLUSIONS Pasireotide appears to be a cost-saving treatment following PD across a wide variation of clinical and cost scenarios.
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Pedrazzoli S. Pancreatoduodenectomy (PD) and postoperative pancreatic fistula (POPF): A systematic review and analysis of the POPF-related mortality rate in 60,739 patients retrieved from the English literature published between 1990 and 2015. Medicine (Baltimore) 2017; 96:e6858. [PMID: 28489778 PMCID: PMC5428612 DOI: 10.1097/md.0000000000006858] [Citation(s) in RCA: 131] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Pancreatoduodenectomy (PD) is one of the most technically demanding operations challenging surgeons, and a postoperative pancreatic fistula (POPF) can complicate an otherwise uneventful postoperative (PO) course. This review examined the methods and procedures used to prevent postoperative pancreatic fistula (POPF) after pancreatoduodenectomy (PD). METHODS A comprehensive systematic search of the literature was performed using PubMed (Medline), Embase, Web of science, and the Cochrane databases for studies published between January 1, 1990 and December 31, 2015. English language articles involving at least 100 patients undergoing PDs carried out in centers performing at least 10 PDs/y were screened for data regarding the Grade of any POPFs according to the definition of the International Study Group on Pancreatic Fistula (ISGPF) and the overall rate of PO mortality related to POPF. RESULTS We reviewed 7119 references through the major databases, and an additional 841 studies were identified by cross-checking the bibliographies of the full-text articles retrieved. After excluding 7379 out of 7960 studies, because they did not meet the eligibility criteria, the full texts of 581 articles were examined; 96 studies were excluded at this point, because they concerned partially or totally duplicate data that had already been reported. The remaining 485 articles were screened carefully for POPF-related mortality and POPF Grades as defined by the ISGPF. Of the 485 articles, 208 reported the POPF-related PO mortality rate and 162 the Grades (A, B, and C) of POPFs in 60,739 and 54,232 patients, respectively. The POPF-related mortality rates after pancreatojejunostomy and pancreatogastrostomy were similar but were less (0.5% vs. 1%; P = .014) when an externally draining, trans-anastomotic stent was placed intraoperatively. The incidence of the different Grades of POPF Grade was quite variable, but Grade C POPFs were associated with a PO mortality rate of 25.7% (range 0-100%). CONCLUSIONS The POPF-related mortality rate has remained at approximately 1% over the past 25 years. Only externally draining, trans-anastomotic stents decreased the POPF-related mortality rate. However, adequately designed venting drains were never tested in randomized controlled trials (RCTs).
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Tajima Y, Kawabata Y, Hirahara N. Preoperative imaging evaluation of pancreatic pathologies for the objective prediction of pancreatic fistula after pancreaticoduodenectomy. Surg Today 2017; 48:140-150. [DOI: 10.1007/s00595-017-1529-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 03/31/2017] [Indexed: 12/13/2022]
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Perioperative application of somatostatin analogs for pancreatic surgery-current status in Germany. Langenbecks Arch Surg 2016; 401:1037-1044. [PMID: 27628685 DOI: 10.1007/s00423-016-1502-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Accepted: 08/19/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND The most common major complication after pancreatic resection is the postoperative pancreatic fistula (POPF). Somatostatin analogs can reduce POPF, but the use of somatostatin analogs is still controversial. The aim of this study was to assess treatment algorithms for pancreatic surgery in Germany with a special focus on the application of somatostatin analogs. METHODS A questionnaire evaluating the perioperative management-especially the use of somatostatin analogs-and postoperative complications after pancreatic surgery was developed and sent to 209 German hospitals performing >12 pancreatoduodenectomies per year (the requirement for certification as a pancreas center). Statistical analysis was carried out using SPSS 21. RESULTS The final response rate was 77 % (160/209), 14.5 % of hospitals never, 37 % always, and 45 % occasionally apply somatostatin analogs after pancreatic surgery. A (standard) drug of choice was defined in 64 % of hospitals. When standard and occasional usage was analyzed, it appeared that hospitals favored somatostatin (69 %) > sandostatin (50 %) > pasireotide (5 %). A relation between the usage of the different somatostatin analogs and morbidity (POPF) or mortality (84 and 16 % of hospitals reported <5 and 5-10 %, respectively) was not seen. Eighty-seven percent of hospitals were interested in participating in future studies analyzing somatostatin use. CONCLUSION This is the first national survey in Germany evaluating the perioperative application of somatostatin analogs for pancreatic surgery. Despite controversial results in the literature, the majority of German pancreas surgeons apply somatostatin analogs perioperatively. The ideal drug to reduce POPF is still unclear. This uncertainty has aroused significant interest and prompted surgeons to participate in future studies in order to elucidate this issue.
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Predictors of successful non-operative management of grade III & IV blunt pancreatic trauma. Ann Med Surg (Lond) 2016; 10:103-9. [PMID: 27594995 PMCID: PMC4995476 DOI: 10.1016/j.amsu.2016.08.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 08/08/2016] [Accepted: 08/08/2016] [Indexed: 12/15/2022] Open
Abstract
Introduction Although surgery is the preferred treatment for grade III&IV pancreatic trauma, there is a growing movement for non-operative management. in blunt pancreatic trauma. Very few studies compare operative versus non-operative management in adult patients. Methods Retrospective analysis of a prospectively maintained database was performed from 2004 to 2013 in the department of gastrointestinal surgery, NIMS, Hyderabad. Comparative analysis was performed between patients who failed versus those who were successfully managed with non-operative management. Results 34 patients had grade III/IV trauma out of which 8 were operated early with the remaining 26 initially under a NOM strategy, 10 of them could be successfully managed without any operation. Post-traumatic pancreatitis, Necrotizing pancreatitis, Ileus, contusion on CT, surrounding organ injuries are independently associated with failure of NOM on a univariate analysis. On multivariate logistic regression presence of necrosis& associated organ injury are factors that predict failure of NOM independently. Development of a pseudocyst is the only significant factor that is associated with a success of NOM. Conclusions Non-operative measures should be attempted in a select group of grade III&IV blunt pancreatic trauma. In hemodynamically stable patients with a controlled leak walled off as a pseudocyst without associated organ injuries and pancreatic necrosis, NOM has a higher success rate. Non-operative measures should be attempted in a select group of high grade (grade III/IV) pancreatic trauma. Controlled leak walled off as a pseudocyst, absent necrosis&organ injuries predict high success rate for NOM. Dedicated nutritional, gastrointestinal and interventional radiological support are the key components of care.
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